Injury to the right foot+DM+Hypertension+SOB

JAHNAVI CHATLA

MBBS 4th year

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 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.


This case is about a 65 year old Gentleman who was an RTC driver 15 years back

Although the patient has been changing hospitals since  the past 30 days, I would like to start his history from 10 years back

10 YEARS AGO

The patient then was a 55 year old man working on different part time jobs for his Daily living

Driving rental cars

Works in his very own vegetable shop

He felt weak and not well for a few days for which he visited local hospital and was diagnosed to be Hypertensive 

He was kept to Antihypertensives and now is on

T-Aten-Am 50mg

5 YEARS AGO



The patient one day was helping someone who was cutting a tree by holding the branch which was being cut with the help of a rope

He got injured by a stone in the rope to his left palm

This was followed by pain, swelling and blackish discolouration 

Then was when he was diagonosed incidentally as diabetic and was kept on medication 

He is now on Tab. Metformin 500mg

4 YEARS AGO

He drank and drove following which he had an accident 

He drove back home and was taken to hospital from there.

There was 

1.fracture to his Left ribs (5,6,7) at mid clavicular line

2.Punctured his lung when led to hemoptysis and suffered for a month


30 DAYS BACK




While he was going out for work, he stepped over a sharp stone which penetrated through his right little toe

He used medications from the local medical store for about 10 days 

He noticed 

1. Increase in pain gradual

2. Edema till his knee which was gradual

3. Bleb formation of about 3*3 cm on the dorsum of his foot which he ruptured by piercing a safety pin through it

There was bleeding from the site after piercing and it continued for a few days and formed into an ulcer.

4. Low grade on and off fever 

5. There was difficulty in urination 

Dysuria

Burning micturition 

Hematuria

Reduced urine output

He then went to a government hospital in Nalgonda and was diagnosed to be AKI on CKD and was transferred for private hospital 1 for dialysis

There he developed SOB of grade 2-3, orthopnea and PND 

He unwent through Dialysis 1

Due to money restraint the patient was shifted to private hospital-2  9 days back

PRESENTATION

Ulcer of right foot since 20 days

Decreased urine output (dysuria, hematuria, burning micturition ) since 20 days

SOB of grade 2-3, orthopnea, PND since 10 days

Generalised anasarca 

DAILYSIS 2 

He had itching at his abdomen, back and left and right Axilla 

DIALYSIS 3 and 4 done

Patient is feeling better comparatively but still has low urine output and SOB





PAST HISTORY

Alcoholic 90ml everyday since 40 years

Chronic smoker 1 pack since 40 years

Hypertensive since 10 years

Diabetic since 5 years

Not a case of Asthma, tuberculosis, epilepsy 


FAMILY HISTORY

The patients mother is diabetic

None of the other family members have similar complaints

DRUG HISTORY

T-Aten-am 50mg

Metformin500mg

No known allergies

PERSONAL HISTORY

Diet- mixed

Appetite- reduced since 3 days

Sleep - inadequate

Bladder - decreased  

Bowel- regular 

CROSS CONSULTATION NOTES

30/12/2021








31/12/2021







GENERAL EXAMINATION 

The patient is coherent conscious cooperative, and well oriented to time place and person

He is moderately built and nourished 

Pallor- absent

Icterus- absent 

Cyanosis- absent

Clubbing-absent

Edema- present pitting Type 

Lymphedenopathy - absent






Vitals:
Temperature- afebrile
Pulse rate- 68 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 160/90 mm hg
SpO2- 99% at room air






SYSTEMIC EXAMINATION

CVS 
S1and S2 are heard 
         No murmurs are heard

Respiratory system:
Dyspnoea- present
Breath sounds- decreased breath sounds in right 
Vesicular breath sounds are normal
Rt side Fine Crepts present 
BAE- positive

Central nervous system-
Patient was conscious coherent and cooperative.
Speech was normal.
No slurred speech
No meningeal irritation signs 
No abnormality detected.
GAIT - Normal

Abdomen
Soft and non tender

INVESTIGATIONS 

31/12/2021
BUN 100
S.creatinine 7
Sodium 130
Potassium 3.4
Chloride 96
Total bilirubin 1.18
Direct bilirubin 0.38
Alkaline phosphatase 189
Total proteins 5.8
Albumin 2.4
FBS 93










Creatinine values
2/01/2022 9.5
6/01/2022 9.4
8/01/2022 8.4
8/01/2022





DIAGNOSIS
 AKI ON CKD SECONDARY TO RIGHT LOWER LIMB CELLULITIS(DIABETIC FOOT)


TREATMENT 
31/12/2021
IVF.NS OR RL UO+50ml/ hr
INJ Lasix 40mg iv/BD
INJ Pipaz 2.25gm iv / TID
INJ nodosis 500mg po/TID
CAP BioD3 0.2mg po/Od
Mgso4 dressing for R. Lower limb cellulitis
RLL elevation 
Monitor vitals
Charting
GRBS 6th hrly
Inj HAI s/c 8am 2pm 8 am

01/01/2022
Add on
Tab ni cardio 5mg Po/Bd

02/01/2022
Add on
Slat restriction
Fluid restriction 
Tab nicardia 10mg

03/01/2022
Add on 
Pan 40mg/bd

06/01/2022
Add on
Inj clindamycin 600mg Iv/TDS

08/01/2022
Add on
Oint thromboprobh




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